Abstract

Graduate nurse practitioners (NPs) face numerous challenges transitioning from registered nurse to advanced practice nurse. They struggle with role identification, communication and teamwork as well as other professional issues. Nurse practitioner residency programs have been developed at a few locations across the country. These programs are rare and generally found only at larger organizations. As many NPs are hired individually in small practice settings, NP faculty at a small private university in northeast Florida developed an academic based nurse practitioner transition to practice program designed to ease the transition to practice for graduating NPs.

Introduction

The transition from Registered Nurse (RN) to Nurse Practitioner (NP) is marked by an array of emotions – from joy and excitement for a new career to stress and anxiety on assuming a more autonomous role. Since the inception of the NP role 50 years ago [1], health care has become increasingly more complex requiring new graduates to possess extensive knowledge and skills to successfully practice.

Hart and Bowen [2] surveyed nearly 700 newly licensed NPs and report that 90% of them felt either “well prepared” or “somewhat prepared” for practice upon completion of their NP program. However, the majority of them also indicated they would have had a strong interest in a post graduate residency program (lasting up to 12 months) if one had been available. Almost 50% of those surveyed felt they practiced outside of their competency level during their first year in practice. Increasingly, residency programs have been identified as an avenue to ease NP transition to practice.

The Institute of Medicine report, The Future of Nursing, recommended increasing the number of NP residency programs as one of several initiatives to advance nursing practice [3]. While the numbers remain small, NP residencies are increasing in number and location across the United States [4]. The National Nurse Practitioner Residency and Fellowship Training Consortium (NNPRFTC) was established in 2010 and reports over 50 post graduate training programs for NPs are currently in existence. The NNPRFTC is working to set standards for residency programs and has established accreditation guidelines for NP residencies [5].

This paper will briefly review the history of NP residencies program and discuss a transition to practice program that was developed at an academic institute.

Review of Literature

NP Program overview

The first NP residency program was established in 2007 at Federally Qualified Health Centers (FQHC) in Connecticut [6]. Today there are over 50 post graduate residencies and this number continues to rise [7]. Although the majority focus on primary care, there are residency programs designed for new graduates certified as adult gerontology acute care NPs, pediatric NPs and for NPs choosing specialties such as urology, orthopedics and emergency [8].

Although attempts have been made to establish consistency in these programs, even the name of the programs remains controversial. Terms found in the literature used to describe these programs include orientation, residency and fellowship. Sciacca and Reville [7] point out that while the American Nurses Credentialing Center recommends the use of the term residency for programs designed for new graduate RNs and fellowship for programs designed for RNs holding licensure for at least one year, there is no recommendation of their use by NPs.

Program design

Structure of the programs vary as well. The majority of the programs last 12 months and consist of both clinical and didactic support [6,8-12]. Also included are opportunities for networking, socialization and mentoring [10,12,13]. Clinical support includes smaller patient panels and exposure to specialty clinics including knowledge of referrals and available resources [9,11,13].

A common thread in most of the residency programs is their implementation at large health care organizations that hire multiple NPs. The Veteran’s Administration established a residency program for individual hires although the structure could be used at VA clinics and hospitals across the country [13]. Both Sargent and Olmedo [11] and Flinter [6] established programs at Federally Qualified Community Health Clinics. Bahouth and Esposito-Herr [14] established a 12-week orientation program for hospital based NPs at the University of Maryland Medical Center. Despite a shorter duration, this program consisted of similar concepts of the 12-month residency programs and focused on both infrastructure issues, networking/mentoring as well as education. Goldschmidt, Rust, Torowicz and Kolb [15] also established a 3-6 month orientation for NPs working in a cardiac center. Each new NP was given an individualized plan; components included a skills checklist and opportunities to interact with NP peers. Wallace [16] discussed a graduate residency program established at a large Health Maintenance Organization. Her findings identified major components of a residency program that should include focus on the complexity of the health care system as well as partnerships and role formation and satisfaction. Varghese, Silvestri and Lopez [17] report on a pediatric NP residency that was established in collaboration with a pediatric ED and three local university Pediatric Nurse Practitioner program directors. The residency was found to increase knowledge, confidence and experience of staff and was viewed favorably by both the NPs and medical staff.

Technology has also been used provide transition support. Thabault, Mylott and Patterson [9] describe a residency program designed for new NPs hired by MinuteClinics, a retail clinic found in CVS pharmacies across the country. The residency program was a collaborative effort between CVS/Caremark and Northeastern University. The participants in this program were paired with an onsite preceptor but the NPs were located in different regions of the country. Technology was used to facilitate case conferences and Webinars. Both the new NPs and preceptors were enrolled in an online doctoral level course on interprofessional collaboration in health care, population health and business concepts applicable to the NP.

Outcomes

Sciacca and Reville [7] performed a systematic review on NP evaluation in postgraduate programs. While they noted there was no standard evaluation method in these program, options for evaluation included self-assessment, competency measure, mentoring, portfolios, simulation based learning and written evaluation. They felt that portfolios were best able to capture professional growth and development in the NP role. While many of the programs profiled reported satisfaction with the residency program, specific outcomes were not often found.

Flinter [5] tracked NP visit volume, patient panel size, procedures performed of participants in the residency program offered Federally Qualified Health Centers in Connecticut. Additionally the novice NPs were evaluated by experienced preceptors. At the time of Flinter’s [6] publication, 15 of 16 participants remained employed at a FQHC. Goldschmidt et al. [15] reported that the orientation program NP working in a hospital cardiac unit met program goals but that financial goals were not calculated. Retention and satisfaction goals were met. Thabault et al. [9] noted that retention was 100% for those NPs who completed their program offered through MinuteClinics.

Several researchers have evaluated residency programs. Most residency programs covered concepts such as leadership, collaboration and practice. While almost all programs report participant satisfaction with the residency, many programs did not evaluate outcome and cost measures, including sustainability. Brown et al. [18] evaluated residency programs offered through the Veteran’s Administration and recommended that outcome measures (patient volume, readmission rates, productivity as well as retention and recruitment of staff) should be analyzed.

Zapatka et al. [19] interviewed NPs who completed the residency program developed through the Veteran’s Administration. Their qualitative study identified four common themes valued by the participants: Bridging into professional practice, expanded appreciation of health professional’s roles, commitment to interprofessional teamwork and the necessity of mentorship.

Academic-based Transition to Practice Program

Two NP faculty at a small, private university in Northeast Florida initially became interested in NP transition to practice due to feedback from their graduates. Faculty were receiving reports of novice NPs resigning from first NP jobs after a few months due to dissatisfaction with the practice and their role within it. These newly graduated NPs were reporting that they were expected to perform at a high volume pace very soon after starting in these practices. They also found themselves working beyond their scheduled daily end times to complete patient documentation, follow-up on labs/diagnostics, and return phone calls from patients. Additionally, both faculty received numerous emails and phone calls from the graduates asking questions about contracts and negotiations, clinical concerns and role expectations. While this content is covered in the student’s final practicum course, their insecurity as NPs lead them to feel the need to verify their knowledge when confronted with these issues.

In this region, the majority of NPs work for one of several local hospital systems that maintain primary care offices and oftentimes do not have peer support at the individual office practice. Other new grads may opt to work for privately owned and/or specialty practices, again often as the only NP at their site. There is a large teaching hospital affiliated with a major university within this city but it is a satellite to the main campus 90 miles away. There are no HMOs established in this region that provide clinical services nor are there any large federally supported community health centers. As a result, many new NPs are hired individually and may not have the opportunity to network with experienced NPs. To date, there are no NP residencies available in this community as most NPs are hired individually and not part of a larger cohort of new NP graduates.

The university offers both MSN and DNP FNP tracks although the DNP track was only recently launched and to date has had no graduates. Although other NP tracks are currently being offered (Adult Gerontology Acute Care and Psychiatric Mental Health have both been recently introduced) the transition to practice program was only offered to MSN/FNP graduates. To provide support for novice FNPs transitioning to their new roles, the two faculty established an academic-based transition to practice program. Although the university does not have an on-campus clinical setting, the faculty felt that the transition to practice program could provide novice NPs with some of the same components found in organizational based residency programs as described above.

A needs assessment survey was conducted approximately three months before a cohort of 25 FNP/MSN students graduated. The response in support of the transition to practice program was overwhelming (21 out of 25 indicating that they would participate if possible). Therefore, the two faculty went about designing a program to meet their needs. The program was designed to begin shortly after the new NPs graduated from the educational program. This afforded the new graduates time to achieve FNP certification and for most to begin exploring employment options. Outcome measures were based on graduate satisfaction with the transition to practice program and if participants felt it helped ease their transition to the NP role. Longer term goals of greater retention in first NP jobs was not tracked due to the short period of the program.

The transition to practice program was designed to meet once monthly, on campus, in a casual, non-threatening environment. The university has a riverfront pub that has space for meetings and receptions. As the transition to practice program took place during the early evening hours over the summer months following graduation, the pub was an ideal place to meet and relax and watch activities take place on the river. FNP alumni from previous years were also invited to participate. Food was provided by the faculty who received a small stipend from their department. The specific goal of the transition to practice program was to support new graduates in their transition from RN to FNP.

The transition to practice program was offered over four months (meeting once monthly), with a focus on what was most relevant to the majority of attendees. It was anticipated that graduates would be in varying degrees of their NP transition. Some graduates started in jobs within a month of graduation and others were still exploring options for FNP employment at the conclusion of the program. Nevertheless, the topics were provided in a logical sequential order and while negotiating contracts might not be relevant to an NP already working, that individual had their own personal experiences they were able to share.

Based upon a review of the literature on NP residencies, four topics were decided upon: First Job, Getting Started, Showing Your Value, and Giving Back. The First Job transition focused on interviewing, negotiating contracts, practice reporting structure, time management (including patient scheduling) and prioritizing. This was most beneficial to those graduates still exploring options for NP positions but not yet hired. Getting Started topics involved discussions on obtaining hospital privileges, establishing protocols and clearly understanding scope of practice. Perspectives on scope of practice was an eye opening experience for many of the new graduates especially for those pursuing positions outside the realm of primary care. Meeting number three was titled Showing Your Value. By this point, most of the new graduates had begun working as NPs and this meeting addressed topics such as billing and coding and managing outcomes. The graduates were beginning to appreciate their value to the practice and wanted to ensure that they were capturing this information to use in support of future performance appraisals and for salary increases. The last topic, Giving Back, focused on networking, mentoring, precepting NP students and explored options for future roles in teaching and research. By this point, most of the new graduates were becoming more secure in their NP roles and had begun looking to the future and how they could give back to their profession. As mentioned previously, these topics are covered in the graduates’ educational program but because most of the attendees were transitioning to new roles, the information was particularly relevant to them now and the graduates could apply concepts that were important to them and ask specific questions about their own situations.

Although faculty prepared booklets for each participant to use as reference material and provided an outline each month, it was not uncommon for the meetings to turn to other topics. Former classmates were happy to catch up on what each person was doing, specifically in regards to NP role transition. Some still contemplating potential NP positions sought advice and support from their peers while others expressed feelings (both positive and negative) about activities from their own NP practice. A few times, the expected topic for that session received less consideration than planned. However, on occasion, the planned topics were very timely to recent events in the participants’ transitions. Faculty chose to take their cues from the NP participants rather than hold strictly to the planned agenda.

Twenty five students graduated from the FNP program in this particular cohort and were invited to participate in the academic transition to practice program. Of the 25, 15 participated in at least one session of the transition to practice program with six attending all four meetings. One FNP alumni attended all four meetings but no other alumni participated. Those not participating were mainly graduates who lived too far away to attend the meetings. Participants completed a program evaluation at the conclusion of the program and overwhelming supported the academic transition to practice program and appreciated that they were not left “adrift” at graduation. Terms such as “comforting, built confidence, empowering” were used to describe the program. The transition to practice program was so well received that an additional meeting was requested and a fifth month was added to the program. Although no set agenda was planned, participants continued to appreciate the support and encouragement from their former faculty and NP peers.

Future Plans

The two faculty plan to continue hosting an NP academic transition to practice program for each graduating class. Faculty will take feedback received from previous attendees and continue to adapt the program to meet new graduate needs. Both faculty feel strongly that curriculum in NP programs need to focus more on NP role transition and this recommendation has been provided to other faculty teaching in the NP program. While often not discussed until near the program completion, integrating topics throughout the curriculum may provide some benefit. Both faculty hope the transition to practice program will allow NP alumni to remain connected with the university and allow for greater networking. This will give new graduates the opportunity to discover practice trends in the community and recognize marketplace demands for their services. Additionally, participants in the NP transition to practice program may be more inclined to serve as preceptors in the future. Lastly, this program demonstrates the value of NP faculty remaining connected to their graduates. NP faculty are important role models during the educational process but their value to new grads may be even higher during the transition to NP practice.

Wallace D. Clinical Inquiry: exploring the feasibility of a new graduate transition to practice residency that supports the nurse practitioner in a large HMO setting. 2012. Unpublished Doctoral Dissertation. Western University of Health Sciences, Pomona, CA.